When to start hypertension treatment
Hypertension Explained Clearly - Causes, Diagnosis, Medications, Treatment, Pathophysiology
welcome to another MedCram lecture we could talk about hypertension and
specifically we're going to talk about the definition why talking about
hypertension is important and then the treatments and I really want to dedicate
this first video to the treatments simple treatments of hypertension and
how you choose medications to treat hypertension so for number one what's
the definition of hypertension well the a and C seven actually defines this for
us and the definition is simply any blood pressure that is greater than 140
over 90 now there's different stages there's stage 1 hypertension and that
would take you from 140 to 159 and then the diastolic would similarly be 90 to
99 so this would be stage 1 stage 2 hypertension on the other hand would be
anything greater than or equal to 160 over anything greater than or equal to
100 this would be stage 2 hypertension it's just a way of telling you what the
different stages are obviously the higher the stage the worse the
hypertension is now why this is important is pretty obvious because we
know that just from studies that high blood pressure leads to a whole bunch of
things you know things like stroke
things like ischemic cardiomyopathy things like a hypertensive heart disease
coronary artery disease and these things are all associated with very bad
outcomes obviously and so if we can reduce blood pressure we can reduce
these things and studies have shown that if you reduce blood pressure by even 5
millimeters of mercury so if we just drop the blood pressure again by 5
millimeters of mercury we can see a reduction in stroke
by 34% that's 1/3 that's pretty dramatic ischemic heart disease can be reduced by
21% and so that's pretty good you could also see a decrease in
dementia heart failure mortality from cardiovascular disease and so forth so
these reductions here are actually pretty pretty good and doesn't take much
to drop your blood pressure by 5 millimeters of mercury so I really
haven't told you something that you haven't already known
what's the treatments let's talk about the treatment and I would be remiss if I
didn't tell you about lifestyle changes we've got to make sure that we include
lifestyle anytime you have a blood pressure that's elevated we have so much
evidence now that lifestyle actually helps with blood pressure we're talking
about dietary changes so diet a low sodium diet is instructive now we're
talking about physical exercise
there's other things called biofeedback relaxation meditation but again I think
dietary is key with low sodium they talked about a - diet you've heard of
the - diet so things that are rich in nuts whole
grains fruits and vegetables
okay so vegetarian diet is very good for reducing blood pressure but of course
the thing that we get tested on in addition to lifestyle is medications and
that's what I kind of want to dedicate the rest of the talk to because
medications have side effects
now nuts whole grains fruits and veggies don't have side effects so this
obviously is a very good thing to do whereas medications are sometimes you're
forced to use medications and medications have side effects and so
this is the real philosophy when it comes to starting medications on
patients with high blood pressure because really there are so many
different types of blood pressure medications out there and you don't
start blood pressure medications because you don't know whether or not it's good
to reduce blood pressure because you know that these medications are going to
reduce blood pressure that's what they're designed to do
so what makes you decide which blood pressure medication to start it's based
on two things number one what the underlying diagnosis is because certain
blood pressure medications help in certain diagnoses and number two what
are the comorbidities that your patient has because these medications have side
effects and you want to make sure you get the right side effect profile so
that's what we're going to talk about next is these medications and their side
effects and how to choose which one to have so there are many different types
of blood pressure medications the way I want to divide this
is in a way that's easy for you to remember obviously and so in this first
video we're going to talk about the four major types of blood-pressure
medications and I like to call this the a B C and D of blood pressure
medications so what is a stand for well a stands for ACE inhibitors and a are
B's B stands for beta blockers C stands for calcium channel blockers and D
stands for diuretics now I know that there's other types of medications for
instance like alpha blockers nitrates vasodilators alpha-2 agonist we're going
to talk about that in the next video but let's first talk about these major types
of medications okay so ACE inhibitors let's talk about
the diagnoses that make ace inhibitors useful so we like to use ace inhibitors
in patients with blood pressure elevation who are what well we know that
in diabetes this can help with kidney problems and it protects the kidneys we
also know that in congestive heart failure it can improve ejection fraction
so that's important to know we know that it helps in post MI it improves survival
it also improves survival and CHF so make sure you know those things because
if you're patient happens to have diabetes or happens to have congestive
heart failure or how it happens to be post myocardial infarction these are
things that help we also like to use ace inhibitors
in patients with connective tissue disease like scleroderma okay and that
also protects the kidneys okay all right so those are the diagnoses that I would
concentrate on what about beta blockers so beta blockers we like to use beta
blockers in again patients with congestive heart failure if we know that
it improves survival we also like to use beta blockers in post MI again for the
same reason it improves survival data blockers arm can also be used in young
and I would also put young here in terms of ACE inhibitors young people who have
problems with blood pressure C's these typically work well in young
people I'd also put a white here as well Caucasian young white we find that it
seems to be more effective in that population in terms of congestive heart
failure the ones that you should know are the two special types of beta
blockers that should be used in congestive heart failure is carve a
Dalal and metoprolol if that's what you're using it for you need to use
those two medications because those are the only two beta blockers that have
been found to improve survival in the studies for CHF for post mi you can use
just about anything but generally speaking carve a delimit overall should
be used in those situations as well all right what about calcium channel
blockers calcium channel blockers really haven't been shown to improve survival
in any patients and so we don't really use calcium channel blockers to improve
survival and so they don't get much of an indication here but you should know
that in African American and in the elderly
they could be useful and that goes the same for diuretics
again diuretics really haven't been shown to improve survival in any
condition and so I would recommend that you know that african-americans seem to
actually respond well to them and also the elderly okay so those are diagnoses
where you'd want to use those medications in those particular patients
what about side effects let's talk about side effects okay so we'll just put a
line here and we'll go over the side effects so you'd want to know the side
effects of these to avoid these problems so what are the side effects of ACE
inhibitors and ARVs the first thing I want to talk about is
angioedema so that's where the tongue swells the next swells this could really
be a problem so you make sure you know that the patient knows that if this
happens they can go to the emergency room and we see it both in ACE
inhibitors and AR B's both cough we see in patients 30% of the time on the Aces
and of course if we see that we switch them to an ARB because we usually don't
see that as much but some of the cut more common side effects would be
hyperkalemia hyponatremia also we see problems with the creatinine especially
in renal artery stenosis so if you have bilateral renal artery stenosis that's
contraindicated you shouldn't use it in those situations obviously you can have
increases in creatinine and that can cause renal failure which is kind of
paradoxical because these are medications that are used especially in
problems with the kidneys to protect from protein area especially in diabetes
so be aware that you know what those side effects are for the ACE inhibitors
okay what about side effects for beta blockers now of course you know that
beta blockers can cause the heart rate to go down that's almost not even a
that's almost a known response obviously they're going to drop blood pressure as
well but some of the other things you may not know is that it could increase
your lipids and cholesterol it can increase depression if they've got
asthma it can increase asthma and COPD with bronchospasm so depression
hyperlipidemia decreased heart rate increased asthma bronchospasm these are
all side effects of beta blockers it could also increase potassium as well so
that's something to keep in mind especially if someone has a hyperkalemia
to begin with beta blockers can can do that calcium channel blockers you really
should divide these up into two different categories there are the
dihydropyridine and there are the non the hydro pyridine x' okay so what are
the dihydropyridine let's switch to a different color to highlight what what
it is that I'm talking about so the dihydropyridine x' or anything that ends
in a beam like nifedipine the feta peen em low to peen and also full-load opine
so no feta P&M low doping and falow to peen these are all dihydropyridine x'
what's the reason why you should know about this it's because they cause
peripheral vasodilation whereas the non dihydropyridine for instance diltiazem
and verapamil cause reduction in inotrope what does that mean that means
it reduces contractility of the heart
as a result we typically see the heart rate go down in this non de hydro
pyridine x' and we see the heart rate go up or stay the same in the
dihydropyridine x' now there is an exception to that and that is m low to
peen that's kind of like the black sheep of the family
and low to peen tends to make the heart rate go down which is which is good
because this is very good in ischemic heart disease so if you want to use a
dihydropyridine and don't want to cause the heart rate to go fast you can
actually use a amlodipine which is still a dihydropyridine but it doesn't make
the heart rate go as fast so that's a favorite one to use in ischemic heart
disease so what are the other side effects that you could see from these
calcium channel blockers well you could see edema in the lower extremities you
could also see constipation and you could see heart failure why again
because of this negative ion at ro- contractility this is a really good
medicine to use in atrial fibrillation with rapid ventricular response these
non dihydropyridine because they reduce the response through the AV node and
aren't going to transmit the electrical conduction of atrial fibrillation which
is going so rapidly that the ventricle can't keep up and it will block that
transmission alright so those are calcium channel blockers what about
diuretics well diuretics is such a broad term I think what we ought to do is
break it down into the two major diuretics and those are the thighs IDEs
so I'll just abbreviate that as hydrochlorothiazide and of course lasix
now of course the the differences between these two can be major there are
a number of side effects of hydrochlorothiazide first of all
hydrochlorothiazide is an a sending limb diuretic whereas lasix or furosemide is
a loop diuretic okay so what there are four things that you should know that
hydrochlorothiazide increases we know that diuretics is a general rule
decrease potassium so we'll put that on both sides but what are four things that
hydrochlorothiazide will increase number one it will increase calcium levels
whereas lasix decreases calcium levels in the blood the second thing that
hydrochlorothiazide increases is uric acid and so that can make gout worse the
next thing that it could increase is lipids and then the last thing that
hydrochlorothiazide can increase is glucose which you have to sometimes
worry about in diabetes so the four things I'll ask you about is calcium
uric acid lipids and glucose of course hydrochlorothiazide reduces potassium
and because it's a diuretic it can also increase your cratan and put you into
renal failure it can also reduce your sodium concentration and it's sometimes
the cause for a hypotonic hyponatremia which is hypovolemic if you want more
information on that look at our med creme lecture on hyponatremia is as a
result lasix gets rid of calcium gets rid of potassium it could also cause
hyponatremia and it can also increase the creatinine and cause renal failure
so these are the four basic food groups if you will of medicines that you can
treat patients with hypertension so let's just go over these a few just in
your mind here if you had a patient with gout you would not want to put them on
hydrochlorothiazide because it could increase the uric acid level if you had
a patient with kidney stones you would not want to put them on something that's
going to put a lot of calcium into the urine like lasix because it drops
the serum calcium level by dumping calcium into the urine whereas a
thiazide diuretic would be ideal since it reduces the amount of calcium that is
excreted into the urine and thereby increases the serum calcium
concentration now in the next video I'm going to talk a little bit more about
some of these other antihypertensive medications like alpha blockers alpha-2
agonist s' nitrates etc so please join me for that
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